13
Key Elements, Priorities, and Next Steps

Key Messages Noted by Participants

Participants agreed that continued research on food insecurity and obesity is needed to answer the questions policy makers and the public have about how and why the two coexist, and that longer funding cycles will enable important questions to be answered.

Such research is important because it will help to guide modifications of food assistance programs and to maintain public support for these programs.

Comprehensive analyses of food purchases, acquisitions, and consumption can be achieved by linking data from different sources.

Multiple federal agencies are interested in the possible links between food insecurity and obesity.

Several participants affirmed that communications research is needed to uncover better ways of framing and disseminating the results of research on food insecurity and obesity.

Research on the framing of obesity and food security from an individual perspective needs to be enhanced by more research on community level research in these areas.

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Key Elements, Priorities, and Next Steps
Key Messages Noted by Participants
• Participants agreed that continued research on food insecurity
and obesity is needed to answer the questions policy makers
and the public have about how and why the two coexist, and
that longer funding cycles will enable important questions to
be answered.
• Such research is important because it will help to guide modi-
fications of food assistance programs and to maintain public
support for these programs.
• Comprehensive analyses of food purchases, acquisitions, and
consumption can be achieved by linking data from different
sources.
• Multiple federal agencies are interested in the possible links
between food insecurity and obesity.
• Several participants affirmed that communications research is
needed to uncover better ways of framing and disseminating
the results of research on food insecurity and obesity.
• Research on the framing of obesity and food security from an
individual perspective needs to be enhanced by more research
on community level research in these areas.
177

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178 HUNGER AND OBESITY
In the final session of the workshop, several speakers representing gov-
ernment agencies and one official from a private foundation summarized
the key messages and suggested actions from the previous 2.5 days. The
moderator, Patricia B. Crawford, director of the Atkins Center for Weight
and Health at the University of California at Berkley, encouraged panelists
to reflect on the workshop content and discuss next steps to help increase
our understanding of the relationship between food insecurity and obesity.
Although much progress has been made in recent years, much more remains
to be done, the panelists said. The potential for research and practice to
improve the lives of people who struggle with food insecurity and obesity
demands redoubled efforts.
A PERSPECTIVE FROM THE FOOD AND NUTRITION SERVICE
Is there value in continuing to examine the relationship between food
insecurity and obesity? “I’m going to say a resounding yes and give you
two reasons why that’s the case,” said Carol Olander, director of Family
Programs Staff in the Office of Research and Analysis at USDA’s Food and
Nutrition Service (FNS), which sponsored the workshop.
Rationale for Conducting Research
First, a vocal contingent of policy makers and a significant segment
of the public cannot fathom how it is possible for people to be both poor
and obese. This group asks, if the poor or food insecure are overweight or
obese, why do they need additional food or nutrition assistance? “That’s
the world I live in,” said Olander.
To provide a persuasive and compelling answer to this question, a
large body of complicated information needs to be distilled into a succinct
message. “I originally thought about having this workshop with the idea
that perhaps we would be able to walk out of the room, not necessarily
with sound bites, but at least with the armament to move in that direction.
That’s not quite the case.” Yet the lack of a succinct message at present
demonstrates not only why additional research is needed, said Olander, but
also some of the directions in which that research must go.
The second reason she cited for looking at the relationship between
food insecurity and obesity is that the government has an obligation to
demonstrate that it is a good steward of tax dollars. This calls for either
a succinct message about the relationship or research aimed at providing
that message.
Finally, the mission of FNS has evolved from a focus just on hunger
to the broader issues of healthful diets and making good food choices. For

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KEY ELEMENTS, PRIORITIES, AND NEXT STEPS
example, the change in name of the Food Stamp Program to the Supple-
mental Nutrition Assistance Program reflects that shift in emphasis. “We’ve
moved from being about food assistance programs to being about nutrition
assistance programs.”
To fulfill this mission, FNS needs to support efforts that respond to
both food insecurity and obesity. Olander cited Marlene Schwartz’s concept
of “nutritious food insecurity” as an important contribution of the work-
shop to meeting this objective.
Consideration of both food insecurity and obesity inevitably generates
tension. With food insecurity, the emphasis is on more—more resources,
more access, more calories. With obesity, the emphasis is on being more
selective if not more restrained. Exploring and understanding this funda-
mental contrast “is essential to being able to go forward and get the sort of
support that is necessary to continue programs that are intended to serve an
increasingly large population in this country,” said Olander.
Takeaway Messages
She cited several takeaway messages that emerged from the workshop:
• Further cross-sectional comparisons of overweight and obesity
among different populations are not needed. “The additional re-
turn for the effort is probably not as worthy as it might be in
pursuing some other paths in the research arena.”
• Many other factors besides food security mediate the relationship
between access to food and obesity. These factors could jointly
cause obesity and food insecurity, or they could exert causal influ-
ences in either direction.
• Many research directions could provide useful information. Ex-
amples include ethnographic studies that look at the coping strate-
gies that households use; longitudinal and retrospective studies
that examine changes in or the persistence of food security and the
likelihood that these have cross-generational influences; examina-
tion of the source, type, and quality of the foods that a household
purchases and consumes; longitudinal research on the relationship
of stress and depression to food insecurity and obesity; and case
studies that look at how food potentiates the link between food
insecurity and obesity, as when the members of a household share
food or experience disrupted eating patterns.
• Measurement issues remain important, with respect to both so-
cioeconomic status and obesity itself, which would seem to be a
simple concept but in fact is not straightforward.

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FNS is announcing a competitive grants program focused on childhood
hunger, said Olander. It also is conducting studies on where people in a
household get food, participation in farmers’ markets, and where recipients
of Supplemental Nutrition Assistance Program (SNAP) funds spend their
resources. For example, a recent study analyzed national data to determine
how many different types of stores SNAP recipients go to, how often they
shop, and what they spend. The average number of transactions for a
household is more than seven per month. Most of the dollars are spent in
the first half of the month, with relatively few resources left for the end of
the month, and most of the dollars are spent in supermarkets and super-
stores. Less than 5 percent of these households never shop in a supermarket
or a superstore in the course of a given month.
The workshop produced many ideas about how changes to programs
could be tested. Examples include alternative SNAP delivery schedules
and a focus on family and community wellness. Olander pointed out that
legislation can constrain such experiments. Appropriations generally come
through very specific line items tied to particular programs, but as legisla-
tion at the federal and state levels is reauthorized and otherwise changed,
these constraints can be lifted.
A PERSPECTIVE FROM THE ECONOMIC RESEARCH SERVICE
The interaction between food insecurity and obesity is one element in
the larger issue of how to alleviate both. As a result, said Laurian Unnevehr,
director of the Food Economics Division of USDA’s Economic Research
Service (ERS), understanding this interaction enriches and enlarges work
on effective interventions.
Linking Different Kinds of Data
Unnevehr briefly described the investments USDA has made in linking
data of different kinds, which is a way of capturing many characteristics of
interest to researchers. For example, efforts are under way to link National
Health and Nutrition Examination Survey (NHANES) data with administra-
tive data to have a clearer picture of food assistance program participation
and benefits. These data also are being linked with price data to have a better
measure of the economic environment and how it may influence health out-
comes. In addition, spatial data on the food environment from the American
Community Survey are being linked with other kinds of data.
These various projects are laying the groundwork for a comprehensive
survey of food purchases and acquisitions both at home and away from
home. The data will cover where the household shops and will be linked
to program participation data, providing an opportunity to look at how

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KEY ELEMENTS, PRIORITIES, AND NEXT STEPS
acquisition might be shaped, for example, by participation in multiple
programs. More information on the project is available in the Diet Quality
and Food Consumption Briefing Room on the ERS website. Data delivery
is expected in 2013 and will be shared with the research community in
subsequent years.
Food Environment Atlas
Unnevehr also briefly mentioned a project on food deserts and the food
environment. A Food Environment Atlas provides data at the county level
on food deserts as well as what have been called “food swamps”—areas
in which large relative amounts of energy-dense snack foods inundate
healthful food options (Rose et al., 2009)—and the variety of food choices
that may be available in a neighborhood. This project provides a national
context for microspatial studies.
Intramural Research on Food Insecurity
USDA has been supporting intramural research on persistent food inse-
curity and the potential limitations of programs to address food insecurity.
It also is looking at the relationship between food expenditures and food
security, which is particularly important in an era of volatile food prices
and economic recession. Another area of long-standing interest is food as-
sistance and health outcomes. Understudied questions include the impact
of the Supplemental Nutrition Assistance Program for Women, Infants, and
Children (WIC), critical stages in development, and impact of participation
in multiple programs on shaping food choices. The result of such research
could be “a fuller picture of how policies can play a role in addressing either
food insecurity or obesity or both.”
Extramural Research on Food Insecurity
On the extramural side, USDA was preparing a request for propos-
als on the impacts of the recession and the role of food assistance in the
broader safety net of social programs.
Federal Partnerships for Research on Food Insecurity
ERS and FNS are partnering in part to use new tools made available
through behavioral economics, which is just one example of potential fed-
eral partnerships.

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A PERSPECTIVE FROM THE NATIONAL INSTITUTES OF HEALTH
Food insecurity is a “hidden phenomenon,” said Wendy Johnson-
Askew, public health nutrition and health policy adviser for the Division of
Nutrition Research Coordination within the National Institutes of Health
(NIH). “Nobody comes out and tells you they don’t have enough money
for food.” Surveys may or may not be able to determine what people are
experiencing, although obesity can be an objective measurement. The co-
existence of food insecurity and obesity can generate confusion for policy
makers and members of the public. Even researchers can be hesitant to talk
about this relationship if discussions seem to threaten necessary programs.
However, exploring the connection is critical, said Johnson-Askew.
“We have to be bold, we have to be the advocates, we have to be able to
explain to people and steer this conversation so that people get a better
understanding of how these two things exist.”
Core Measures and Procedures
NIH is interested in funding the best research it can fund, she said.
Greater than 70 percent of NIH-funded research is investigator-initiated.
In light of the mixed results of food insecurity and obesity studies she rec-
ommended agreeing on a set of core measures and procedures that can be
incorporated in studies to measure the same things in the same way. Some
areas of consideration for inclusion in core measures are: Should marginal
food security be combined with low and very low food security? Should the
population of interest be below 185 percent, 200 percent, or 250 percent of
the federal poverty line? Which measures of socioeconomic status should
be used in models?
Johnson-Askew suggested the following as areas in which more re-
search is needed:
Communications research. Researchers are not necessarily skilled
•
at getting their points across to the public and reacting to the
public’s questions, said Johnson-Askew.
Food choices. Many factors go into these decisions, not just money.
•
Behavioral economics could make important contributions to how
people make these decisions.
Food acquisition. We need more information on where people are
•
getting their food. “Food pantries, though they fill a great niche,
are not acceptable ways for families to have to come once a month
and get 3 days’ worth of food,” said Johnson-Askew.
Social networking. This is a hot topic at NIH, and social networks
•
undoubtedly influence nutrition behavior.

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A variety of lenses. Historical trauma, life course perspectives, and
•
child health are all additional lenses through which to view obesity
prevention.
NIH has substantial resources that it devotes to nutrition and obesity:
4 percent of the NIH budget goes to nutrition research, representing expen-
ditures of $620 million annually, and 8 percent of that is targeted toward
obesity. Much of the research funded in the past has been on interventions
research. What happens if this one thing is changed? Food insecurity and
obesity are very dynamic states. Currently there is a groundswell of interest
in systems research, which fits well with the multifactorial nature of obesity
and holds promise for helping to understand the relationship between food
insecurity and obesity.
A PERSPECTIVE FROM THE CENTERS FOR
DISEASE CONTROL AND PREVENTION
Most of the work done by the Centers for Disease Control and Pre-
vention (CDC) occurs at the community and state levels, said Commander
Heidi Blanck, chief of the CDC’s Obesity Prevention and Control Branch.
The CDC division that contains her branch funds adolescent and school
health and adult and community health, with an increasing emphasis over
time on the environment, policy, and systems approaches. Blanck said that
CDC’s portfolio is helping communities make the more healthful choice
the easy choice.
The goals of CDC include increasing diet quality, increasing physical
activity, and reducing obesity. These goals can be met by helping Americans
to eat healthfully and live actively. Reducing obesity is a goal, but healthful
relationships with the food environment and physical activity are routes to
that goal.
Unintended Consequences of Policies
One thing CDC has examined is possible unintended consequences
of policies. For example, will enhanced menu labeling worsen disparities
among groups, some of which may not have the education, income, or
health literacy to react to healthful incentives? Will emphasis on retail ven-
ues, farmers’ markets, or farm-to-school programs enable equitable food
choices?
It is one thing for government to emphasize the importance of fruits
and vegetables and quite another to ensure access to those foods. The
administration has been emphasizing programs such as the Fresh Food
Financing Initiative to fill the “grocery gap,” but it also has been working

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on options that restrict consumption, such as limiting the consumption of
sugar-sweetened beverages. Viewing such issues from the perspective of
food insecurity has been helpful, said Blanck, because it is a valuable addi-
tion to the diet quality perspective.
Food Policy Councils and Community Food Security Coalitions
Blanck included the importance of food policy councils and community
food security coalitions, which are groups of advocates and stakeholders
that have the potential to do the following:
• Engage in discourse about meeting the needs of multiple groups
including agriculture, public health workers, and lower-income
individuals;
• Provide technical assistance for state and local communities to
think about food access and anti-hunger; and
• Invest in interventions demonstrated to be effective.
The Farm Bill
The Centers for Disease Control and Prevention is convening stake-
holders to consider public health in the reauthorization of the farm bill.
Research on food insecurity and obesity can be a way to bring together
people from different areas to work on these broader issues.
The National Collaborative on Childhood Obesity Research
CDC is part of the National Collaborative on Childhood Obesity Re-
search (NCCOR), which has brought together several large public- and
private-sector organizations interested in childhood obesity and food security.
A PERSPECTIVE FROM PRIVATE FOUNDATIONS
For the past 6 years, The California Endowment, which is a private
foundation dedicated to improving the health of Californians, has been fo-
cused on a community-based, comprehensive obesity prevention initiative,
said Marion Standish, director of The California Endowment’s Community
Health Program. This initiative has sought to frame the program around
the community, not around individuals, which has implications for both
research and practice. “We want to move from this narrow frame around
outcomes of obesity to these larger frames of community priorities to im-
prove health,” she said.
One objective is to look carefully at the places where people live. The
relationship between food security and place is “profound,” said Standish.

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Geographic information system (GIS) mapping of poverty, food security,
school meal participation, and other measures related to socioeconomic
status and food access find enormous geographic concentration. “A good
solution solves many problems, and I think in this instance, a focus on
place offers us the opportunity to address both food security and obesity
simultaneously.”
Focus on Prevention
Standish expressed the opinion that prevention had not been empha-
sized enough in the workshop. Once obesity has taken root, it is hard to
undo. How can the problem be shifted upstream to the community factors
that contribute to obesity? Communities recognize the importance of the
same things researchers do in obesity prevention, including access to health-
ful food, safe places to play, and walkable neighborhoods.
Policy and systems change requires working with community members
and parts of systems. It also requires research to evaluate multisectoral
approaches.
• Which influences in the community environment offer the most
promise for interventions?
• To what extent do those influences need to be changed?
• How many playgrounds, food stores, or food benefits are neces-
sary to make communities food secure and eliminate obesogenic
environments?
• How can longitudinal research be sustained to assess the long-run
impact of policy on behavior?
The involvement of the National Institutes of Health in this research
would be extremely welcome, said Standish. Currently, the resources to
evaluate community change are very limited.
GROUP DISCUSSION
Moderator: Patricia B. Crawford
During the group discussion period, points raised by participants included
the following:
Funding Cycles
The panelists discussed how the typical funding cycle for research at
NIH can be harmonized with the study of long-term interventions. One
option is to change the funding cycle, although in an institution as large

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as NIH that it not easy, said Johnson-Askew. Another option is for NIH
to provide support for organizations that can conduct long-term research,
such as NCCOR. Foundations also may be able to fill some of the gaps that
NIH cannot fill, she said.
Improving Program Evaluation
Standish pointed to a healthful food initiative that will represent a
shared investment between the U.S. Department of the Treasury, USDA,
and the Department of Health and Human Services. “There needs to be
an evaluation of that initiative that goes beyond did we actually invest in
stores or operators to—Did we really deliver healthful food? Did people
choose healthful food? Who was choosing healthful food? Where were they
coming from to get to those places? . . . I know funders are interested in
this as well—a robust, multiagency, coordinated evaluation to address this
one very important issue of access to healthful food.”
Measuring Community Food Security
In response to a question about whether the federal government intends
to invest in methods to measure community food security, Blanck said
that CDC is sponsoring a survey that will look at how health planners are
assessing access to food and water to glean environmental measures that
could augment geographical data. CDC also has tools that communities
can use for planning and evaluation. Lila Rutten mentioned a new resource
developed by the National Cancer Institute called the Grid-Enabled Mea-
sures Database, or GEM, which is an online data repository that is based
on wiki technologies so that contributors can add what they think are the
best measures of nutritional intake, physical activity, and so on. “It’s an
opportunity for the scientific community to vet, comment on, and modify
those measures.”
Communications Research
Valerie Tarasuk emphasized the need for communications research. “A
lot of the arguments that have been made over the last 3 days around the
need for more research on the relationship between food insecurity and
obesity have been rooted in concerns about the way in which perceptions
about fatness are being used to raise questions about the legitimacy of
poor people’s needs for benefits. I would suggest to you that this is not a
matter of science, or at least not solely a matter of science. Pouring more
money into scientific endeavors to try to elucidate whether or not there is
a relationship and what the biological pathways are will probably not be

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enough to silence those who would raise questions about the legitimacy of
benefits for people who are living in poverty.”
Standish emphasized that the framework for health issues in the United
States is oriented toward self-reliance and individual choice. “To the extent
that we are trying to identify [other] factors, it’s an uphill climb unless we
have research to help us reframe the discussion.” Standish highlighted the
importance of better understanding community food security and factors
that influence communities.
Edward Frongillo agreed that it is important not only to set a research
agenda but to develop a communications strategy based on the findings of
research. “If there isn’t a counter narrative, we’re in a position of replacing
a narrative that’s out there with nothing. We need to make a story that’s
more realistic and more useful to help improve people’s lives.”
REFERENCE
Rose, D., N. Bodor, C. M. Swalm, J. C. Rice, T. A. Farley, and P. L. Hutchinson. 2009. Deserts
in New Orleans? Illustrations of urban food access and implications for policy. Paper
presented at Understanding the Economic Concepts and Characteristics of Food Access,
Washington, DC, January 23, 2009.

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